Voluntary Occurrence Reporting
From SKYbrary Wiki
A proactive process and related arrangements for collecting information about safety concerns, issues and hazards, which otherwise will not be revealed by a mandatory reporting system.
To facilitate the collection of information on actual or potential safety deficiencies thus contributing to the identification and implementation of safety improvement measures.
According to the recommendations in ICAO Annex 13 - Aircraft accidents and incidents investigation, States should establish, in addition to the Mandatory Occurrence Reporting, a voluntary incident reporting system to enable the identification of hazards and unsafe conditions that have not yet caused an incident. Such voluntary reporting should be non-punitive and afford protection of the sources of information. In order to encourage and promote voluntary occurrence reporting, States may need to adjust applicable legislative and regulatory frameworks and policies.
European Union Recommendations
According to Article 5 of the Regulation (EU) No 376/2014 on reporting, analysis and follow-up of occurrences in civil aviation, “Each Member State shall establish a voluntary reporting system to facilitate the collection of: (a) details of occurrences that may not be captured by the mandatory reporting system; (b) other safety-related information which is perceived by the reporter as an actual or potential hazard to aviation safety”.
Member States are advised, when implementing such voluntary reporting systems, to establish the conditions for de-identification of voluntary reports presented under such systems. This will enable the dissemination of important safety information derived from the analysis of the confidential reporting to all parties so that it can be used for improving safety of aviation.
Incentives for Voluntary Reporting
In a voluntary reporting system, the reporting person, without any legal or administrative requirement to do so, submits a voluntary incident report. To promote the process of voluntary reporting, regulatory agencies should offer incentives to report. For example, enforcement action may be waived for reported unintentional violations. A number of States claim they have included this incentive among the principles of their voluntary reporting systems; however opinions on its successful implementation diverge considerably. The general rule in voluntary reporting systems is that the reported information should not be used against the reporting person, i.e. such systems must be non-punitive, error-tolerant and just in order to encourage further reporting of safety related information.
Key Voluntary Reporting Principles
The following key principles are to be considered when establishing a voluntary reporting system within the generic framework of an organisation’s safety management system (SMS):
- Trust - The reporters must be certain that the information will not be used against them; otherwise they will be reluctant to report their mistakes. A positive Safety Culture in the organisation provides the foundations of a successful occurrence reporting system.
- Non-punitive - The reporting person must be protected against legal, administrative or disciplinary sanctions, except in case of gross negligence, criminal activity or intent.
- Inclusive Reporting Base - The systematic approach to safety management required that voluntary reporting be targeted at all aspects of aircraft operation, such as flight operation, cabin safety, aircraft maintenance, air navigation services, aerodrome operation, etc. Also, collecting information on the same occurrence from different perspectives provides for a complete analysis and understanding of events, and consequently of the hazards and their effects.
- Confidentiality - Non-punitive systems should ideally be based on confidential reporting. The person reporting an incident must be sure that his identity and other information that may be used to identify involved other physical or legal personalities will not be disclosed. In some States legislation on access to information makes it increasingly difficult to guarantee confidentiality. This could limit the safety occurrence reporting to the minimum required for mandatory reporting. Voluntary does not necessarily also mean confidential
- Independence - Ideally, the voluntary reporting system will be operated by an organisation that is separated from the State regulatory authorities. This organisation will collect and analyse safety reports and feed the results back to the regulatory authorities and the aviation community.
- Ease of reporting - Submitting a report should be as easy as possible for the reporter. The reporting forms should be readily available to anyone wishing to file a report. They should be easy to compile, provide adequate space for narrative and make maximum use of the “tick off” format. The forms should encourage safety improvement suggestions, such as how to prevent reoccurrence of a hazard or deal with it.
- Acknowledgment - To encourage further submission of reports the organisation should clearly communicate to its personnel that the voluntary reports are a valuable safety asset and acknowledge the efforts made by reporting persons. Whenever possible, feedback on the actions taken in response to a report shall be provided to the reporting person directly but also in the form of collective feedback to the reporting community.
- Promotion - The de-identified information received from the voluntary reporting system should be made available to the aviation community in a timely manner. A variety of information dissemination methods should be used to achieve maximum exposure, for example monthly newsletters, periodic summaries, safety bulletins published on internet etc. Such promotional activity may help motivate people to improve further the reporting of safety occurrences - failure to do this will reduce the effectiveness and value of the system.
Voluntary Reporting Systems
Many aircraft operators and air navigation service providers have implemented voluntary occurrence reporting systems to improve hazard identification and risk management processes in their organisations. Often, voluntary reporting is integrated into internal company reporting programmes. Examples of such programmes are:
- Aircrew Incident Reporting System (AIRS) - developed by Airbus Industrie to help its customers establish their own confidential reporting systems. In particular, AIRS aims to enhance an understanding of the underlying Human Factors contributing to occurrences.
- International Air Transport Association (IATA) Safety Trend Evaluation, Analysis & Data Exchange System (Safety Trend Evaluation, Analysis & Data Exchange System) - Featuring the world's largest database of de-identified incident reports, IATA STEADES provides a secure forum for the sharing of safety data and its global analysis. The analyses result in trending reports that can be accessed and used to develop a comprehensive list of prevention strategies for a wide range of areas within the air transport industry: airline management, ground handlers, air traffic control units, maintenance outfits, regulators and other industry organisations.
EUROCONTROL implemented in 2007 a system for the collection of voluntary reports related to ATM called EUROCONTROL Voluntary ATM Incident Reporting (EVAIR) function. EVAIR collects and analyses voluntary reports submitted mainly by airlines and ANSPs with the objective to:
- Identify areas of safety concern;
- Facilitate prompt communication between ANSPs and airlines enabling quick feedback at the operational level;
- Assist in identifying and implementing timely solutions to operational safety problems at local, regional and ECAC level.
The added value of EVAIR for the aviation community is that, besides informing about accidents and serious incidents, it also provides information about low risk bearing incidents and supports the identification of early corrective actions.
- Safety Occurrence Reporting;
- Mandatory Occurrence Reporting;
- EUROCONTROL Voluntary ATM Incident Reporting System (EVAIR)
- Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014 on the reporting, analysis and follow-up of occurrences in civil aviation, amending Regulation (EU) No 996/2010 of the European Parliament and of the Council and repealing Directive 2003/42/EC of the European Parliament and of the Council and Commission Regulations (EC) No 1321/2007 and (EC) No 1330/2007;
- NASA ASRS website.
- The Transition From Event Reprts to Measurable Organizational Impact: Workshop Proceedings Report, Avers et al., FAA, 2014